TN 14 (03-97)

Our records show that    A    received    B    more in Social Security benefits (on behalf of    C    ) than    D    should have. (Include paragraph to explain the overpayment.)

On    E    and    F    we wrote    G    about the overpayment and the amount    H    should repay. Since we have not received any reply to our letters, we are asking your help in resolving this matter.

Please personally contact    I    and take the action requested in the enclosed instruction sheet.

Enclosures:

SSA-3560
SSA-632-BK
SSA-795

The explanation of the overpayment will include information regarding the months overpaid, the amount payable each month, the amount paid monthly, and the total overpaid amount. If the overpayment resulted from the entitlement of another beneficiary, the adversely affected individual must be informed of the name, relationship to the wage earner, and the bases for the entitlement of the new beneficiary.

Fill ins:

1. Overpaid person

2. Amount of overpayment

3. If representative payee, show beneficiary's(ies) name(s)

4. He/she/they

5. Date of previous overpayment notice

6. Date of previous overpayment notice

7. Payee or beneficiary

8. He/she/they

9. Overpaid person